MEDICARE: MRS. SAMANTHA M MACKINNON RD, LD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	1076848	TX

General Provider Information

NPI Number	:	1558839100
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SAMANTHA M MACKINNON RD, LD

Provider Business Mailing Address
First Line	:	1369 ARLINGTON ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77008-4568
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1369 ARLINGTON ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77008-4568
Country	:	US
Telephone Number	:	470-533-6100
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/12/2018
Last Update Date	:	11/12/2018

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